Consider referral of very high fracture risk patients to an osteoporosis specialist in secondary care, for assessment and consideration of parenteral treatment (some may need first-line anabolic drug treatment, especially those with multiple vertebral fractures). Indications for specialist referral include:

1. • The presence of single but important clinical risk factors, such as,
     • A recent vertebral fracture [within the last 2 years]
     • ≥2 vertebral fractures [whenever they have occurred]
     • BMD T-Score ≤-3.5
     • Treatment with high dose glucocorticoids [≥7.5 mg/day of prednisolone or equivalent over 3 months] (refer urgently given rapid loss in bone post initiation of glucocorticoids; if any delay is anticipated, start an oral bisphosphonate in the meantime)
   • The presence of multiple clinical risk factors, particularly with a recent fragility fracture indicating high imminent risk of re-fracture.
   • Or other indicators of very high fracture risk.